Our NHS People

Learning from the British Army

A perspective from an Army GP

Military planning normally starts a long way before the decision to go to war but in this Covid-19 case the war has come to us. The NHS is on the frontline without the luxury of the preparation phase so these three slides talk through the GP version of some of the military planning process in use, for comparison. 

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Extracts of the presentation by Colonel Ali Everest

Military defence is based on the premise that if you want peace you have to be prepared for war. This is achieved by ‘training, planning and training some more’: before action there is a pre-deployment brief to explain to the troops what they can expect when they deploy and this briefing reinforces the leadership teamwork and communication are the essential elements for success and that people really need to look after themselves and others. 

At the end of the campaign there is a little “coming home” process so when leaving what’s normally a theatre of operations it is commenced by an exit operational stress management briefing to explain to people what they are going to go through emotionally as they come out of the war zone and return back to their families. Sometimes there is an opportunity to do a formal decompression called a third sector decompression. For example, in the the Afghan years transit through Cyprus providing several days where people would literally sit on the beach together, drinking tea, talking through their experiences still in the groups that they’d been in the difficult environment with, but shifting environments and staying together and talking through it and they were supported by their welfare and pastoral teams. 

Once back into the the UK there is a normalization process which includes another briefing and often this may be giving people what might seem to be sort of mundane tasks: the unpacking kit and cleaning weapons while talking to each other and assimilating back into the climate.

The next step that we usually have is two weeks of or more of post-operational tour leaves, and that’s essential because that’s re-integrating people back with their families who’ve been coping without us while we’re away and they they have an amazing role in returning us to be “normal”. So that’s lots of talking and squabbling and playing with the children and just getting on with normal life 

So that’s the sort of initial process and then at the 12-week point we have a discussion with the chain of command, so that’s what we call our line managers. And this is the opportunity for your line manager to ensure that there are no issues with you, and where possible this briefing/debriefing is done by the chain of command because they’re the people who are out there with you and they’re the ones who understand what you went through, so this is really valuable and gives you that sort of psychological safety. 

We also have something called Trauma Risk Incident Management (TRIM) this is peer-to-peer review and it’s about supporting and signposting people so each unit has got a number of people who are trained up as TRIM practitioners and they’re responsible for this process and it’s all about peers and mentioned before about psychological safety so things that you can say to somebody who’s your peer and has been through the same things that you’ve just been through and their job is checking in on you and giving you permission so you know recognising that is okay to not be okay but supporting you with signposting to expert help if the persistent symptoms persist or if you you need it 

So we recognised with this COVID situation it’s not going to be a six-month deployment we’re not going to have an obvious endpoint and there’s not going to be a coming home or leave for everybody. The Army and the NHS were pretty busy before this crisis and when it ends there’s not going to be a real holiday and people spoken about the fact that you know there’s going to be a backlog of cases to be dealt with and it feels like we’re going from a hundred and twenty percent to the normal hundred and ten percent but we need to make space for people to rest and recover and we need to understand what they’ve been through. Some people fare better than others: most people are okay (and we’ve mentioned the TRIM posters to keep an eye on people) but I think is important to understand that people react differently and sometimes this is due to the perception of threat which is something we/you talk about in a military context but it’s very very real here where people have been talking about their the dangers that they feel to so many aspects of their life and COVID.

So somebody who’s doing a difficult task maybe somebody who’s a mortuary assistant in this crisis might actually do really really well emotionally because they’ve been well they’ve been well prepared, they recognise the value of their role, providing respect and dignity for the bereaved, and they’re in a good team that’s well led. 

Conversely someone who’s in an unfamiliar role at home with maybe less work responsibilities or unwell but stuck in a confined space with a teenager maybe at their wit’s end and we know from our military research that individuals may sometimes fare worse than those who deploy as formed teams and this really illustrates the importance of leadership and teamwork in coping with this crisis. It’s helpful if you go through it with your normal team but we actually have the opportunity to build new teams that we’re working in now and that can help protect our protectors 

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So I’ve mentioned leadership and I’d like to just very briefly talk about Army leadership. This is a slide that distils down a fraction of the the enormous amount that’s written about army leadership but to me I think this is the the two most important bits. So army leadership is a combination of character knowledge and action. It’s no good being a marvellous person if you don’t actually do something about it and if you don’t have the knowledge then you can’t act so those three legs of the stool are essential, and also I think the way it’s written it inspires others to succeed. The motto at Sandhurst is ‘Serve to Lead’ and I think the selfless organisation of the NHS has the same altruistic principles.

The army leadership code is a framework for leadership behaviour and it builds on our military values and standards which you can see on the slide, and these are probably very familiar to people in the NHS because there’s so much in common between the NHS and the military. 

A friend of mine sent me some alternatives and he said that at the minute what we need is kindness, tolerance and flexibility and I think certainly, at the minute, those those three are probably what we need.

I need to also stress that leadership is not just about the senior officers directing a campaign. This is leadership at all levels just as it was in Afghanistan when we had the strategic corporals leading patrols out on the ground making critical decisions and really looking after the team. Recently the army sgt. major sent a message to all the junior non-commissioned officers telling them that they’re the linchpins of the army and never more so than in this current crisis and he charged them with the responsibility of looking after their teams and not to underestimate the value of a kind word or a phone call to check in on on people 

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The final slide is one of the projects that we’re working on now is a mental health project called op smart and this slide is an illustration of the mental resilience training concepts that we’re working on and it shows the seven pillars of the house that make up your mental resilience. We use this model to consider how these are affected for each individual and these circumstances and what we need to do collectively as a team to rebuild these pillars. And you can see the little circles at the bottom and these are the five skills that we talked about setting goals for the team and you can see they’re thinking positive, emotional control, anxiety regulation, mental rehearsal and these are mental fitness training skills that we learn so you can train yourself to be mentally fit and we think this provides a framework to understand what stresses we’re experiencing and how to combat this. 

So, to finish, we believe that there should be a recovery process which recognises leadership and understands mental fitness and we recognise that we need to recover as a team and that we need to stay together we need to acknowledge what we’re all feeling and we need to communicate with one another

Basically it’s about looking after yourself and your team whilst being courageous; demonstrating the integrity and selfless commitment — the values that the NHS and the military have in common.